SEA08FA161

NTSB accident investigation · Cessna 441 · Sunriver, OR · July 16, 2008

Accident · FatalField investigationFinal report
Date
July 16, 2008, 10:15 local (17:15 UTC)
Place
Sunriver, OR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Landing
Aircraft
N441HKCessna 441
Defining event
Landing-flare/touchdown: Hard landing
Weather
Visual (VMC) · Day
Status
Completed · report June 11, 2009
Report
Approved by Office Director
Parties
Portland FSDO
FAA report
20080716840459A
Case key
68448

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's misjudged landing flare and improper recovery from a bounced landing, and the pilot's failure to maintain directional control during the go-around after one of the airplane's propellers struck the runway.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: landing flareAircraft › Aircraft oper/perf/capability · Incorrect use/operationCessna 441: 1 caseAll aircraft: 1,285 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 441: 1 caseAll aircraft: 3,958 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 441: 6 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was executing a day visual flight rules full-stop landing and touched down on the main landing gear near the approach end of the runway. Soon after the initial touchdown, the airplane became airborne again. Instead of initiating a go-around, the pilot attempted to continue the landing sequence. During that attempt, the airplane bounced on the runway three or four times, each time the rebound back into the air and the runway contact was more severe. During the last contact the airplane impacted the runway with sufficient force to result in the failure of the right main landing gear actuator rod, and in the right propeller contacting the runway surface multiple times. The pilot then initiated a go-around, but since the right engine had failed due to the multiple propeller strikes, the airplane produced asymmetrical thrust and began to roll to the right, veering off the right side of the runway. Soon thereafter its right wing collided with a tree and the airplane impacted terrain in an open field. The airplane was consumed by fire shortly after the collision. Postcrash inspection found no evidence of mechanical failure or malfunction with the airframe or either engine.

Factual narrative

HIISTORY OF FLIGHTOn July 16, 2008, about 1015 Pacific daylight time, a Cessna 441 Conquest, N441HK, impacted the terrain about 400 feet east of the runway at Sunriver Resort Airport, Sun River, Oregon. The private pilot, who was the sole occupant, was killed during the accident sequence, and the airplane, which was owned by the pilot's corporation, was destroyed by the impact and post-crash fire. The 14 Code of Federal Regulations (CFR) Part 91 personal transportation flight, which departed Bakersfield, California, about two hours and fifteen minutes prior to the accident, was being operated in visual meteorological conditions. The pilot filed and activated an Instrument Flight Rules (IFR) flight plan, but canceled his IFR clearance as he approached Sun River.

According to a friend of the pilot, the pilot and members of his immediate family had flown into Sunriver three days earlier (Sunday, July, 13). The purpose of that flight was to drop off the family members, who were going to visit with a friend of the pilot's wife who lived in the resort community. After dropping off the family members, and refueling the airplane, the pilot flew back to Bakersfield the evening of July 13.

According to friends of the family, on the day of the accident, the pilot intended to fly to Sunriver, have lunch with his family, and then he and his wife were going to meet with a realtor to look at a residence that was for sale near the home of his wife's friend. The pilot then planned to fly his family back home to Bakersfield later that afternoon or evening. Reportedly there was no set departure time from Sunriver, and the pilot intended to return to Bakersfield whenever the day's activities concluded.

As the pilot approached his destination on July 16, he terminated his IFR clearance at 0955, while about 20 miles south of the Sunriver Airport. Soon thereafter the pilot contacted Sunriver Unicom (the common traffic advisory frequency for the airport), and was given the current altimeter setting and advised that the winds were 337 degrees at four knots. After thanking the person who transmitted the altimeter setting and the winds, the pilot stated that he was going to set up for a straight-in for runway 36. A short time later the pilot transmitted that he was on final for runaway 36.

There were a number of witnesses who were watching the airplane as it approached the runway from the south, and they all reported that the approach looked "normal." The pilot-rated witnesses said that the airplane's speed and approach path looked appropriate, and all the witnesses said the airplane appeared to make a normal touchdown on the two main wheels near the south end of the runway.

What happened next differs according to witness accounts. Some thought that after the main wheels touched, the airplane simply bounced, skipped, or hopped back into the air. Others thought the nose wheel touched the runway surface, and then the airplane lifted back off the runway. At least one witness thought that after the mains touched, the nose wheel came down abnormally fast, hit the runway hard, and then the plane bounced back into the air. All agreed that after the first bounce/hop, the airplane contacted the runway a number of times, bouncing back into the air after each contact. All witnesses agreed that the amplitude of each bounce increased as the airplane proceeded along the runway.

After the third or fourth bounce, while the airplane was at a height estimated by witnesses to be between 10 and 20 feet above the runway, the airplane entered a nose-down, right wing-low attitude. It then descended into the runway surface with sufficient force to result in the right propeller contacting the asphalt. This impact took place while the airplane was near the runway's left (west) edge, about 2,260 feet north of the threshold of runway 36. The marks on the runway surface showed that there were 16 propeller blade strikes from the right propeller over a distance of about 23 feet. In addition, there were 12-foot long scars/scratches on the runway surface from both the right main landing gear wheel rim and the nose landing gear wheel rim.

According to some of the witnesses, just prior to, during, or immediately after the propeller contacted the runway, one or both of the airplane's engines increased to what sounded like full power. After the propeller contacted the runway, the airplane once again lifted back into the air, this time in a nose-high attitude, in what appeared to some witnesses to be the beginning of an attempted go-around. According to one witness, who was waiting to initiate a glider tow from near the north end of the runway, and who had a nearly unobstructed frontal view of the accident airplane, soon after the propeller contacted the runway it almost completely stopped rotating.

As the airplane's nose came up, it started to roll to the right, and the airplane started to veer off to the right (east) side of the runway. Soon thereafter the airplane's right wing collided with a 25-foot tall tree about 200 feet east of the runway centerline, and about 845 feet north of where the right propeller had contacted the runway. Upon colliding with the tree, the outboard three feet of the right wing separated, and while still in a right bank angle of greater than 45 degrees, the airplane descended into the terrain in a nose-low attitude. According to a photograph taken immediately after the right wing hit the tree, a trail of fuel was released along the accident path, and soon after the airplane came to rest, a small fire started near the outboard section of the right wing. According to witnesses, the fire soon began to spread, and had engulfed the entire airframe within three to four minutes.

Personal information

The 50 year old pilot held a private pilot certificate, with ratings in single-engine and multi-engine airplanes, and an instrument rating for airplanes. According to his flight log, he had accumulated about 965 hours of total flight time. His flight log indicated he had accumulated about 845 hours as pilot-in-command (PIC) of multi-engine airplanes, and about 277 hours as PIC in the Cessna 441 Conquest. He completed a 10-hour Cessna Conquest II Recurrent Training Course on May 3, 2008, and successfully completed an Instrument Proficiency Check on the same date.

The pilot's last medical certificate, a second class, was issued on 8/6/2007. The only listed medical limitation was the requirement to wear corrective lenses.

Meteorological information

The 0956 aviation surface weather observation (METAR) for Roberts Field, Redmond, Oregon, which is located about 30 miles north of the accident site, reported winds 050 degrees at 04 knots, a visibility of 8 statute miles, clear skies, a temperature of 24 degrees Celsius, a dew point of 05 degrees Celsius, and an altimeter setting of 30.14 inches of mercury.

According to a representative of Sun River Resort Airport, at the time the 441 pilot first called Sun River Unicom, the winds were 337 degrees at 04 knots. There were reportedly some areas of scattered clouds around 10,000 feet above ground level (AGL), and the visibility was at least 10 statute miles.

Wreckage and impact information

The outboard section of the right wing was located about 40 feet northeast of the tree that it collided with. The outboard 18 inches of the right aileron was located nearby. The nose of the airplane impacted an open grassy field about 180 feet northeast of the tree impact, on a magnetic heading of 55 degrees. The majority of the airplane's structure came to rest about 275 feet northeast of the tree. The right engine separated from the wing upon impact, and was located about 50 feet beyond the main wreckage on a magnetic heading of 35 degrees from the wreckage. Except for components that separated at the location of the nose cone impact point (nose gear, nose gear door, nose bay hydraulics) all primary airplane structure

Aircraft

Registration
N441HK
Reported as
Cessna 441
Category
Airplane
Serial number
441-0336
Airframe hours
5,643
Engines
Garrett TPE-331-10N, 1,000 horsepower, turbo propGarrett TPE-331-10N, 1,000 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · March 14, 2008
Departed
KBFL · Bakersfield, CA
Destination
S21 · Sunriver, OR
Flight plan
IFR
Airport
S21 · Sunriver Resort, runway 36, 5,500 × 70 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 23, 2008
Seat
Left
Toxicology
Performed
Flight hours
965 total · 277 in this make and model · 53 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.